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0800 612 9376
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01227 772775
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0330 999 7080
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Date of Birth
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Year
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1920
Marital Status
Single
Common Law
Married
Divorced
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Occupation
Licence Type
Full
Provisonal
Other
Period Held (Years)
less than 1 year
1
2
3
4
5
6
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8
9
More than 9 years
Cover Start Date
Day
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Year
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2020
2019
2018
2017
2016
2015
2014
2013
2012
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2010
2009
2008
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2005
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2002
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Level of Cover
Comprehensive
Third Party, Fire and Theft
Third Party Only
Have you had a claim in the last 5 years?
Yes
No
Add claims
Date of claim
Total claim cost
Claim Type
Please enter a value greater than or equal to
0
.
Accident - Not at fault
Accident - Fault
Attempted Theft
Fire
Flood
Hit Whilst Parked
Theft From Vehicle
Theft of Vehicle
Vandalism
Windscreen
Have you had any convictions?
Yes
No
Add convictions
Conviction / Fixed Penalty date
Type of offence
Penalty points
Length of ban (months)
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0
and
12
.
If pending please choose the conviction type only.
Require Additional Drivers
Yes
No
Do you have any criminal convictions?
No
Yes
Vehicle Registration
Vehicle Make
Vehicle Model
Estimated Value (£)
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0
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Is the vehicle modified?
Yes
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Estimated Annual Mileage
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Overnight Parking
Public Road
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Garage
Car Park
Private Property
No Claims Bonus (Years)
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Protected
Yes
No
Do you require cover for any other vehicles?
Yes
No
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